Tuesday, November 30, 2010

Clinical Pearls: Syncope

I'm doing a new thing here. I'm listening to medical podcasts on the way to work, so I'm going to try and share some of the pearls of clinical wisdom I pick up. The sources are a variety of free podcasts available through iTunes.

If you're an experienced provider, you've probably (like me) forgotten a lot of the nifty bits of clinical information that you were taught in school but didn't NEED to know. The stuff that got lost when you were cramming NREMT and ACLS skill sheets in your head. The stuff that might actually be more useful now that you're out in the field.

So that's what I'll try and bring you: Short, sweet tidbits that can help the experienced (or new) provider up their game.

We see syncope a lot. A lot of it is (or seems) harmless, and many of us like to wastebasket it into the vasovagal category, and don't mind getting a refusal.

Try to be more suspicious. Don't get suckered by how good they look now. Think about the patho. If it's not a seizure or low blood sugar, it's probably not enough blood or oxygen getting to the brain. Arrythmias? Stroke? Aortic stenosis or dissection? Occult (you know, hidden) bleed? Pulmonary embolism? There are some big, scary bears that cause syncope, and you should suspect them before you call it a vagal or psychogenic.

But how do you make that judgement? What should worry you?

First, most of these folks warrant a good assessment. Get a real detailed history. Find out if they had symptoms before they syncopized. Get a good set of vitals, and a 12 lead ECG is an excellent idea. Check neuros. Ask friends and family if they are acting normal. Go LOOKING for trouble.

But who are the folks to be worried about?

• Patients with chest or back pain, new onset, before or after the syncope, should be concerning for aortic aneurysm or dissection, or PE, or cardiac causes.

• Patients who don't return to their baseline after a syncope should be concerning for intracranial pathology (CVA/TIA/bleed).

• And patients who have no prodrome, no symptoms before passing out, no dizziness or tunnel vision, those folks should have you worried about weird rhythms.

Vasovagal syncope is not uncommon -- but just like anxiety attack, it should be a (presumptive, field) diagnosis of exclusion, the one you reach after everything else has been exhausted.

Hope this is helpful to some of y'all. More coming soon!

Friday, November 05, 2010


They say we shouldn't do it. They say that Rapid Sequence Intubation - the practice of sedating and chemically paralyzingly a patient to place a breathing tube in their trachea - is too dangerous for paramedics to perform. They say the studies show it's too risky. They say we're not good enough at intubating. They say you can support a person with basic techniques.

They say, they say. And in many cases - trauma in particular - I tend to agree.

And yet.

* * * *

Drugs got him here, and drugs will be his salvation. He wasn't breathing when the fire department EMTs arrived. Narcan helped his respirations, but nothing else. They're not sure what he took.

They've barely stopped bagging when we walk in. Not down too long, they say. History of drug abuse and suicide attempts. So we start the workup.

I start a line in his ankle, the only site I can find. My partner hooks him up to the monitor. He's breathing forty times a minute, but his oxygen saturations hover around 85%. He won't wake up and his lungs sound like a tire chain in a tumble dryer. Even with suctioning, an NPA, and more bagging, he doesn't really improve. His jaw is locked tight, and all I can do is run the Yankauer over his teeth.

The nearest hospital is 35 miles away, on windy, rain-slick country roads.

They say...

We load him in the ambulance, make a few more desultory attempts at BLS airway managment, and then make the decision.

My partner draws up the drugs. I get out my tools -- Options A, B, and C.

My eye briefly lingers on the small cardboard box of Option D. I can picture what's inside, the plastic package and scalpel and Sharpie-scrawled message some wise-ass coworker has left: "GOOD LUCK. STAY CALM."

I leave the cric kit on the shelf. Everything else, though - tube, bougie, King - I lock and load. Line them up neatly. Lights up. Suction running. All the positioning tricks I know. He predicts like a difficult airway, no matter which mnemonic or scheme I use. Nothing good about this. We can't get his sats over 90%.

My partner, holding two syringes, asks if I'm ready. The firefighter assisting us looks at me expectantly.

Well. I suppose. I'd better be, hadn't I?

He pushes the drugs, and I wait until he stops breathing. His jaw loosens, and I slide the blade into his mouth. Everyone is gathered around - the firefighter holding cric pressure, my partner pulling the patient's head into a better sniffing position - and all of a sudden I can see the cords.

"Whoa! Okay, tube, tube. Good. Okay. Through the cords. Stylette out. Balloon up. Get that capnography on. Ears? Okay, bag. Yeah? Sweet."

And then it's all over but secure the tube, clean up, sedation, NG tube, and so on -- all during the long drive in.

He's hard to sedate and fights us some on the way in -- maybe a speedball? -- but his sats slowly come up.

By the time we leave the hospital he's at 100%, sleeping peacefully with the aid of a versed drip. The doc shrugs her shoulders.

"Don't exactly know what's up. We'll have to wait for labs and imaging. Could be a few different things. Sounds like it was a tough one out there. Good job, guys."

* * * *

They say, they say, and sometimes I think they are right, and sometimes I think they are wrong.